Consultation outcome

Government response to minimum service levels in event of strike action: ambulance services in England, Scotland and Wales

Updated 6 November 2023

Ministerial foreword

The ambulance service is a cornerstone of the NHS that ensures people get emergency care and treatment when they need it. So, while the ability to strike is an important part of industrial relations, which gives workers the chance to have their voices heard, it is important that this is balanced against the risk of harm to patients that can occur when strike action takes place.

The government is focused on making the hard but necessary long-term decisions that are in the best interests of the country, to put the UK on the right path for the future. Therefore, earlier this year we consulted on whether the government should introduce minimum service levels (MSLs) for ambulance services during strike action. MSLs exist in a range of countries in Europe and beyond, as a way of balancing the ability of employees to strike with the needs of the public. The International Labour Organization (an agency of the United Nations) recognises that this is justifiable for services where their interruption would endanger citizens’ life, personal safety or health.

This report summarises responses to that consultation. We heard from the public, employers, trades unions, charities and other representative groups. We closely reviewed and analysed written responses and held workshops with these different groups to assess and discuss the different options. I would like to thank Healthwatch for their help in facilitating the consultation event with patient representatives.

As part of the consultation, we heard evidence of where the locally negotiated and voluntary system of derogations^{[footnote 1]} had not worked well during recent strike action. This included derogation agreements being made at the last minute, or services not being manned because of confusion as to what the agreed derogations were. We heard evidence of where individuals and unions had recognised the need to respond to serious cases that required an ambulance response but would not have necessarily been captured by the agreed derogations.

The responses to the consultation showed that there is widespread support for the ambulance service continuing to respond to the most serious calls during strike action. Where there was disagreement was whether the existing voluntary system of derogations is sufficient to provide that minimum level of service, or whether there should be a safety net to ensure that these levels of service are met, even when there is no agreement between employers and trade unions. Most respondents recognised that in the vast majority of cases ambulance unions had ensured that these cases were responded to during the strikes that look place last winter.

While the government has chosen to press ahead with laying regulations which stipulate a minimum level of service during strike action in ambulance services, so that the most serious cases will be responded to, we have adapted our intended approach. Instead of expecting that employers will always issue work notices to ensure MSLs are met, we recognise that they may be able to secure the same level of coverage through voluntary derogations, and they can continue to agree and rely on these instead, as long as they are confident that the MSL will be met. Where employers decide that voluntary agreements are sufficient, this will give union members more flexibility on strike days; instead of either being on strike, or not, they can choose to strike but leave the picket line if needed, as they do currently. Both employers and unions said they valued this flexibility as part of our engagement with them.

I also recognise that restricting the ability to strike, even in the way we are proposing, means that we need to ensure that compensatory measures are in place. I am proud that within the NHS there is already a strong culture of working in partnership with unions through bodies such as the NHS Staff Council, and the national Social Partnership Forum. To strengthen this further, the government is committing that it will agree to engage in conciliation for national disputes in relation to ambulance services, where the relevant unions agree this would be helpful, and I hope and strongly encourage NHS employers to do the same for local disputes. This is a significant and appropriate commitment that balances the ability of workers to strike with the public’s right to life and health.

Thank you to all those who contributed their time and expertise to this consultation.

The Rt Hon Steve Barclay MP
Secretary of State for Health and Social Care

Executive summary

The government’s priority is to protect the lives and health of patients during any industrial action. It is vital to ensure that people have access to the emergency services when they need them. We have consulted on proposals to introduce MSLs in ambulance services to reassure the public that we will strive to keep patients safe no matter what.

Patients receiving care and being taken to hospital by the ambulance service are often at their most vulnerable, and time is often of the essence. During the recent round of ambulance strike action, there was inconsistency of provision of ambulance services across different regions; with resources stretched to the limit, sometimes only the most life-threatening cases received an ambulance. In our engagement with patient representative groups, we found there was uncertainty as to whether certain emergency calls would receive a response. We have heard accounts of urgent cases having to wait until the following day to be attended to.

We also cannot rely on public behaviour and falls in demand to mitigate the risks posed by this. We do not want sick patients to avoid calling 999 on a strike day when they genuinely need an ambulance, which could allow their condition to deteriorate. If demand for ambulance services were to remain as high on a strike day as on a non-strike day, this could result in less stable operations, and voluntary arrangements might not be sufficient to protect patient safety.

We know that ambulance trusts and trade unions worked hard together to come to agreements on which types of cases would be responded to, often working right up to the day before strike action began to finalise plans. However, this was done at a local level, meaning that from one region to the next, there was variation in the agreements made, resulting in a postcode lottery as to which patients would receive an ambulance. There has also been some concern that people who genuinely needed an ambulance did not phone on strike days, either thinking they would not get a response or that their condition was not serious enough. This resulted in services sometimes having to work harder the following day to support patients who subsequently became more unwell. These regulations and the possibility for employers to issue a work notice will ensure certainty during strike action across the country, while of course recognising there will inevitably be some variation if strikes take place in some areas and not in others.

Public consultation

Our consultation asked for views on whether people supported the proposed legislative change, and what the scope of the policy should be, such as which roles in the ambulance service should be included and which types of medical incidents should be responded to with a minimum level of service on strike days. It also asked whether the territorial scope of the regulations should be England only or also include Wales and Scotland, whether we should look at MSLs in wider health services, and about equality impacts.

We analysed a total of 150 responses to the online consultation and further detailed feedback from employers, trades unions, charities and other representative groups received in writing and as part of 4 interactive consultation workshops. Overall, the consultation showed that while most respondents (76%) disagreed with the principle of introducing legislative minimum levels of service in the ambulance service, many of them recognised there were issues and risks associated with the existing approach to agreeing derogations on a voluntary basis.

The main areas of concern participants expressed around MSLs included how the MSLs would compare to the level of service provided when the system was most stretched on non-strike days. We recognise the unprecedented pressure the ambulance service has been facing since the pandemic. That is why we published the urgent and emergency care recovery plan which aims to reduce Category 2 response times^{[footnote 2]} to 30 minutes this year, with further improvements towards pre-pandemic levels next year. Ambulance services are receiving £200 million of additional funding this year to grow capacity and improve response times, alongside 800 new ambulances including specialist mental health ambulances.

Participants were also concerned about the lack of flexibility that legislative MSLs provided for. While under the current system, individuals could be ‘on strike’ but leave a picket line to respond to calls where all sides agreed an urgent ambulance response was needed, implementing MSLs would mean that individuals would either be required to work or on strike. Respondents were concerned that this would meaningfully impact on an individual’s ability to strike, and limit flexibility if more or fewer calls needed to be responded to than anticipated.

Respondents were also concerned about the administrative burden placed on employers by the need to issue work notices. We recognise this concern and, to minimise this risk, we will make clear that the issuing of work notices to staff requiring them to work during strike action, need not be issued, for example if employers are confident that the derogations agreed on a voluntary basis with unions are sufficient to meet the MSL.

A significant element of our consultation was seeking feedback on what level an ambulance service MSL should be set at in order to appropriately balance the ability of individuals to strike with the rights of the wider public to life and health. A large majority of respondents (81%) said that life-threatening cases, such as major trauma or cardiac or respiratory arrest, should be responded to, with a smaller majority (63%) in favour of covering emergency cases including time-sensitive incidents, such as strokes and heart attacks.

We have looked closely at the processes employers and trade unions went through in preparation for the recent round of strike action and decision-making that goes into the prioritisation of 999 calls. This has helped us to understand how the legislation would fit into ambulance service operations and where best to draw the line regarding calls that require an ambulance response.

There is a clear public health rationale for ensuring that cases that are life-threatening and where there is no reasonable clinical alternative to an ambulance response, are responded to. This means it is likely that a high proportion of Emergency Operations Centre (EOC) call handlers, clinicians and dispatchers, and ambulance staff including paramedics and emergency care assistants, will need to be named in a work notice and required to work on a strike day. In order to maintain safe and consistent operations, we have also concluded that most on-call IT staff, on-call emergency mechanics and Make Ready staff are also likely to be required on a strike day.

Having carefully considered the consultation responses and weighed the concerns raised in the consultation with the risk to life and health that strike action in the ambulance service brings, the government has made the hard but necessary decision to introduce MSLs in ambulance services. It is in the best interest of patients and will ensure the NHS is protected from militant strike action in future.

We have, however, adapted our proposed approach to reflect the concerns raised through the consultation process. We will work with employers to support them to implement new regulations. We will also seek to work with employers and trade unions to improve and strengthen the existing process for voluntary derogations, recognising that the inconsistency in approach caused issues during strike action that took place earlier this year.

We recognise that setting MSLs at this level will have a significant impact on the ability of rostered employees to participate in strike action. In order to ensure that these regulations are fair and proportionate, we intend to compensate for the reduction in the ability to strike. by committing to engage in conciliation for disputes, where the relevant unions agree this would be helpful. Further detail on this can be found below.

Next steps

We will take forward legislative changes by making regulations under the Strikes (Minimum Service Levels) Act 2023 (‘the act’) to ensure that work notices may be used within the ambulance sector. We intend to lay the regulations by the end of 2023.

In coming to these conclusions, we have prioritised the safest outcome for patients, while recognising that the ability of trade unions and workers to strike has been restricted. We will now work closely with stakeholders to build on what we have learnt during the consultation, and will work with employers going forward to support them to implement the new regulations.

Introduction

Background and objectives

The government, employers and trade unions all agree that it is important to have some continuity of provision in ambulance services during strike action, where the decision to respond or not respond to a particular case can be the difference between life and death.

Currently during strike action, ambulance service employers and trade unions negotiate voluntary agreements to provide a certain level of cover, so that certain staff members or groups of staff will be either working or on call during strike action to provide working cover for the most life-threatening and emergency cases. These agreements are known as ‘derogations’.

During strike action in the winter of 2022 to 2023, derogations were agreed in ambulance services at a local level. This meant that the response to calls of varying severity was not consistent across the nation. While some areas were responding to high numbers of Category 2 calls as well as Category 1 calls, others were only responding to the most life-threatening cases. Negotiations also continued until hours, if not minutes, before strike action commenced, which made it difficult for employers to put appropriate mitigations in place, and for the government to be confident that this had been done. This resulted in a postcode lottery and made it difficult for the public to understand what level of service would be available.

The government therefore proposed setting national MSLs in the event of strike action to provide more certainty about, and consistency of, provision. It did this while wanting to preserve, as far as possible, the ability of individuals to take strike action, given the important part this plays in the industrial relations landscape in the United Kingdom.

The aim of this consultation was to seek views from all interested parties, including ambulance service workers, employers and the public on whether the government should introduce MSLs for days of strike action and, if so, how to do so most effectively. This document sets out what we heard from the consultation, our response to the points raised and how we plan to take forward our proposals.

Why we need a new approach

Over the 2022 to 2023 winter, 3 unions took strike action in ambulance trusts across England. Voluntary derogations were put in place, but these were agreed through local negotiations between employers and trades unions, and often very shortly before strike action commenced.

Data available from NHS England on ambulance demand and performance during industrial action by ambulance staff^{[footnote 3]} shows there was a fall in the number of ambulance arrivals at A&E on strike days. This likely explains why there was a reduction in ambulance handover delays on strike days. In the week following strike action, there was no consistent rebound in the number of ambulance arrivals at A&E or handover delays. We believe that these changes were driven, at least in part, by public messaging from NHS England, encouraging people to call 999 only when needed and emphasising alternatives. This may have contributed to changes in public behaviour such as patients making their own way to A&E rather than calling for an ambulance.

However, the fall in ambulance arrivals was generally smaller on later strike dates.^{[footnote 3]} This may suggest a change in patient propensity to call 999 during strike action. Over the winter we saw that as the frequency of strike action increased, there was not the same drop-off in demand. We therefore cannot rely on public behaviour to mitigate the risks that an uncertain level of ambulance service creates. We also do not want to create a situation where members of the public refrain from calling 999 when they do need an ambulance, which could allow their condition to deteriorate. If demand for ambulance services remains as high on a strike day as it is on a non-strike day, this could result in less stable operations, and voluntary arrangements might not be sufficient to protect patient safety.

During our workshops and subsequent meetings with the sector, we also heard some evidence of issues experienced on the operational side during the recent round of strikes. We heard feedback on confusion around what should happen on a strike day. For example, there was a case of ambulance staff being on the picket line but ready to respond to Category 1 calls, but no one was in the control room ready to dispatch ambulances for calls coming in for around 2 hours until the mistake was rectified.

Stakeholder engagement

The public consultation ran for 12 weeks. It was open to anyone of any age and was available in both English and Welsh.

To supplement the views provided in the online consultation, the Department of Health and Social Care (DHSC) conducted extensive engagement with stakeholders. We are grateful to all those who joined our workshop events with NHS trusts and organisations, trade unions, professional bodies, charities and patient representative organisations. The topics discussed included:

• the rationale behind the policy proposal
• proposed policy and territorial scope of the regulations
• equality issues
• the practicalities of using work notices
• possible unintended consequences of introducing the legislation

In addition, further stakeholder meetings were held during and after the consultation period. During these meetings we explored further operational details to refine our understanding of operations to ensure we have captured all relevant parts of the service.

We would like to thank everyone who participated in the consultation for their time and thoughtful input.

Methodology

The survey hosted on GOV.UK comprised of closed (quantitative) and open-ended (qualitative) questions. We also received several off-platform responses via email which, unless they specifically referred to any of the closed-format consultation questions, were analysed alongside the open-ended responses.

The consultation ran from 9 February 2023 to 9 May 2023. Shortly after launch, technical difficulties on the online survey meant that the survey was temporarily taken offline for repair, and reuploaded the following week. There were a small number of responses submitted prior to the survey being taken offline - these were analysed alongside subsequently received responses. Where respondents had provided an email address, they were invited to submit a response to questions that were not displayed when they initially took part.

Descriptive statistics of the quantitative responses were produced, which are used to describe and summarise the characteristics of the consultation responses, not to make inference or prediction, or assess the interaction between variables. For each question, distributions of responses were calculated as percentages of those who provided an answer to that question. We have provided a breakdown for overall views on the proposed introduction of MSLs for ambulance services by:

• type of respondent (for example, members of the public, a representative organisation or body, members of the workforce)
• sex
• distance from hospital
• disability

Due to low number of responses, we are not able to provide a summary of response by ethnicity, nation and region. Due to suppression requirements, we have also not included several respondent demographics in the accompanying tables relating to detailed ethnicity, organisation type, organisation region, number of employees an organisation has and detail on job roles.

Responses to the consultation are not representative of the groups referenced, but only of those who chose to respond to the consultation. Where particular groups are referred to or compared - for example, “members of the public are most likely to say…” - this refers only to members of the public responding to the consultation and cannot be taken to represent the views of the public more generally. As such, statistical significance testing has not been used to analyse results. Differences between responding groups have been highlighted using judgement.

We have assumed in analysis that respondents submitted responses in good faith which, if given, accurately represent their characteristics and their view. For example, we take at face value those selecting ‘member of ambulance workforce - paramedic’ are indeed from this group, as verification was not sought.

For ease of reading, we have aggregated positive or negative responses. For example, if 28% were unsupportive and 5% slightly unsupportive, we have written this as ‘33% unsupportive’. These aggregated figures are derived from the frequencies rather than the rounded percentages. In most cases, this would result in the same figure, but may in some cases result in a 1 or 2 percentage point difference from adding together rounded percentages. Results are reported as a percentage of those that responded to the question (for instance, “75% of public respondents agreed with…” should be understood as “75% of public respondents that responded to this question agreed with”). This is omitted for ease of reading, but results should be read this way throughout.

Accompanying data tables have been published alongside the consultation response. These data tables present full breakdowns for each quantitative question in the consultation, in accordance with statistical disclosure controls to protect anonymity, and provide the data used in the analysis section. We have also published a set of data comparing the demographics of the responses to the consultation with the English population and English workforce demographics.

The number of respondents in each of the categories is set out in the accompanying data tables.

The consultation also included 8 open-ended questions where respondents could provide free text responses. Across all these questions, around 16,500 words were received in approximately 330 free text responses. This was in addition to ‘Other (please specify)’ responses which were given to add to pre-defined options shown to respondents.

Responses from key organisations were identified for manual review in their entirety (including those submitted via email) using thematic analysis to code into themes via an iterative process with a team of 4 analysts. These are referred to in the analysis as ‘stakeholders’ or ‘stakeholder organisations’. All respondents’ free text responses for each of the open format questions were also reviewed via the same approach to identify any further themes raised in the responses. Where free text questions followed a quantitative question (for example, “please explain your answer [to the previous question]”), these responses were understood and analysed in context of their preceding quantitative response.

While qualitative analysis is not intended to show exactly how many people held a certain view, we have endeavoured to provide an indication of the weight of opinion in responses, using words such as ‘many’, ‘some’, ‘several’ or ‘a few’. However, it should be cautioned from overinterpreting these terms as we received a relatively low number of responses to this consultation.

Individual quotes have been used, where appropriate, to help illustrate themes. These were selected either as being typical of the responses received, or that they were particularly clear examples of the theme. Quotes are presented anonymously by removing information that could potentially identify them.

Detailed government response

The following sections provide the government’s response to the issues noted in the consultation on minimum service levels in ambulance services. We have grouped the comments we received from participants and presented them broadly thematically to address each overarching policy question.

Minimum level of service

Overall, in the consultation responses and stakeholder roundtables, there was not strong support for introducing statutory MSLs in the ambulance service. However, a large majority of respondents (81%) said that life-threatening cases should be responded to even in times of strike action, with a smaller majority (63%) in favour of emergency cases including time-sensitive incidents. In order to ensure that these calls will be answered on strike days, and assure the public that this will be the case, we intend to make regulations that introduce minimum levels of service. There is no way we can guarantee this is applied across England without legislating for a standardised approach.

Some feedback received during the consultation workshops was that implementing MSLs could worsen relationships between employers and trade unions during a period of pressure, and wherever possible they would want to continue to rely on voluntary arrangements. Alongside working with employers to implement the new regulations, we will support them by seeking to work with unions to strengthen the process of agreeing voluntary derogations. This will mean more employers could be confident on meeting the MSL through voluntary arrangements, and thus be able to rely on these rather than needing to issue work notices. The ‘Wider options’ section of this consultation response provides further detail.

There was widespread concern around strictly defining which types of calls would be regarded as ‘safe’ or ‘unsafe’ to not respond to. Some Category 3 calls certainly require conveyance to hospital by ambulance due to the nature of the condition. An example was given of a patient with a broken femur, which requires specialist care, which could not reasonably be provided through other means, before the patient can be moved from the floor. This means the patient could be waiting on the ground in significant pain if only Category 1 and 2 calls were covered by the statutory MSL or through voluntary arrangements.

Evidence from the recent round of strike action showed that different regions responded to the response categories in different ways. Some ambulance trusts responded only to Category 1 calls, while others also responded to Category 2 calls. There has also been concern that people who genuinely needed an ambulance were not phoning on strike days, thinking they would not get a response. Following the strikes, services had to work harder to help those people who subsequently became more unwell access treatment.

We also heard that there are often decisions that are not clinically led made in the Emergency Operations Centre (EOC) and by trade union representatives on the picket line. Legislating to maintain certainty of the provision of services will help to ensure there are no disagreements around which calls to respond to.

The government’s view is that the evidence heard during the consultation provides a strong foundation on which to proceed with the policy and implement MSLs in the ambulance service.

In light of the consultation responses, we have also carefully considered how to ensure that the policy is proportionate. While the majority (60%) of online responders to the consultation disagreed with the suggested ways of formulating the MSLs in secondary legislation, the option that received the most support (23%) was to require ambulance trusts to respond to ‘all life-threatening and emergency calls’. Regarding some specific urgent cases, key stakeholders raised the need to include these, as some of these calls can be complex and there would be no safe alternative to an ambulance response. We anticipate there are some cases for which there is no realistic alternative to ambulance conveyance to hospital - for example, elderly fallers with injuries, road traffic collisions involving injured motorcyclists and broken femurs.

We have concluded that all calls to the 999 ambulance service, including healthcare professional (HCP) calls, must be answered; and all calls that are life-threatening and where there is no reasonable clinical alternative to an ambulance response, must receive a response as they usually would on a non-strike day. This was informed by discussions with stakeholders, who were concerned about limiting the flexibility of current strike day operations. Crucially, this approach will enable clinicians to judge each case on the day, taking all factors into account in determining the appropriate response. The protection of life and health is the government’s overarching goal, hence the relatively high level at which we are setting the minimum level of service.

Policy scope

As with the principle of introducing minimum service levels regulations, many participants in the consultation did not think any particular profession should have to work on a strike day. However, we received some useful feedback around which specific roles are critical to the continuation of the service.

Our engagement with representatives from ambulance trusts showed that establishing a minimum service level at the level we now propose would generally require around 80% of an ambulance service’s resource on a typical shift. However, we cannot account for sickness or other absences on the day. This drop in service capacity could account for the difference between the 80% of calls we have identified that need to be responded to on a strike day and the additional 20% of calls that would normally be responded to on a non-strike day. It is also not possible to know in advance what the demand will be on any one day. There are many variables - for example, seasonal weather changes or major incidents - which can influence how busy the service is, even using forecasting tools based on previous years. It is possible that additional staff would need to be named on a work notice to address these issues. This means that most, if not all, ambulances in a service’s fleet would need to be staffed to ensure calls that are life-threatening or where there is no reasonable clinical alternative to an ambulance response, are responded to. A high proportion of all levels of paramedics, emergency care assistants and other staff in the ambulance teams rostered to work on a strike day are therefore likely to have to be named in a work notice.

Given that all calls must be answered in order to be triaged and to know whether an ambulance should be sent to them, it is essential that a high percentage of EOC call handlers are at work on a strike day. A high percentage of EOC clinicians are also critical in the call centre, to provide the clinical knowledge required to upgrade response categories for patients whose conditions have deteriorated. Dispatchers are also vital to control and appropriately organise mobile ambulance resources. These are all critical roles to maintain patient safety and must not be carried out by untrained personnel.

Feedback received has highlighted that there are additional groups of essential support staff, such as on-call emergency mechanics, on-call emergency IT staff and Make Ready staff, who maintain essential aspects of the service. Emergency mechanics respond as soon as possible if, for example, an ambulance breaks down while out on the road. Emergency IT staff need to be ready to deal with any technological issues in the event that the system goes down and calls might not go through or contact could be cut off with the ambulance fleet. Make Ready staff are essential to ensure that ambulances are cleaned when required and restocked with equipment and consumables, replacing anything used or missing from the stores.

During discussions around Hazardous Area Response Teams (HART) and Special Operations Response Teams (SORT), it became clear that these are both essential to have at the ready in the event of a major incident. As they need to be ready to respond at any moment, we consider that employers should have the ability to include them in work notices.

We recognise that setting the MSL so that a high number of rostered staff are required to work will have a significant impact on the ability of employees to participate in strike action. There are already a number of measures in place that provide trade unions with the opportunity to represent the voice of ambulance service employees to their employers and to the UK Government which has responsibility for NHS services in England. These include:

• the NHS Pay Review Body, which covers Agenda for Change staff including ambulance workers, and invites evidence from trade unions when producing their reports and recommendations on pay and uplifts
• the NHS Staff Council, which provides a partnership forum for both employers and trade union representatives and has overall responsibility for the Agenda for Change pay system, the terms and conditions of which cover ambulance workers in NHS organisations
• the national Social Partnership Forum, which is attended by NHS Employers, NHS England, trade unions and the Department of Health and Social Care. The forum discusses policy impacting on the NHS workforce which is not covered by the staff council

In order to ensure that the regulations are fair and proportionate, we are committing to engage in conciliation for national disputes, and I hope and strongly encourage that NHS employers will do the same for local disputes.

Work notices

Employers will need to have the ability to identify which workers are required to work on a day of strike action and the work to be undertaken to meet the minimum service level. This will be set out in a work notice. This will enable individuals to know if they need to attend work and the trade union to take reasonable steps to ensure that any of their members who are identified in the work notice comply.

We received feedback during the consultation about the potential administrative burden of using work notices. Due to the high proportion of staff required on a strike day, the number of separate notifications required to these individuals following the issuing of a work notice to trade unions will also be high. Employers estimated that a high number of working hours of entire HR and operational teams will be required to organise work notices and notify employees.

It will be up to the discretion of the employer whether to issue a work notice, in order to ensure the MSL is met, and it is a matter for the employer to consider any contractual or other legal obligations that it has in taking this decision. We want to ensure that the public can access vital services during strikes, but that does not mean a work notice must always be issued for every strike. An employer may be able to achieve an MSL without a work notice being issued. We want to enable employers to make this decision as they are the closest to the day-to-day operation of their services, while considering any contractual or other legal obligations the employer has in taking this decision.

Patient transport services

Although no respondents to the online consultation provided a detailed view on patient transport services, we discussed this issue at length in our subsequent engagement with the sector. There are risks for several groups of patients should they not be able to access patient transport services on particular days.

The non-emergency patient transport services (NEPTS) that stakeholders noted are critical on a strike day are often, but not always, planned services (not accessed via 999 calls), and can include same-day discharge, which can be unplanned. These services provide free transport to and from hospital for people whose condition means they might need additional medical support during their journey and/or for people with mobility issues. Stakeholders flagged some time-critical and therefore high-risk cases of patients whose conditions could significantly deteriorate if their transport and therefore treatment was delayed. These cases were all renal dialysis patients, all oncology and related cancer care patients, all palliative care patients, and any other high dependency patients.

Stakeholders also noted the importance of inter-facility transfer (IFT) services. These services are for patients who require transfer by ambulance between hospital inpatient facilities in order to increase their medical or nursing care. For example, this might be because a patient self-presents at their nearest A&E department with a medical emergency, but the hospital does not have specialist services to treat their condition, therefore requiring the patient to move to another site. The IFT framework in England sets out that Levels 1, 2 and 3, which map to the ambulance response Categories 1, 2 and 3, should be responded to as time-critical emergencies and immediately allocated the nearest appropriate response.

Following discussions with the sector, we want to ensure that some limited but critical patient transport services will be provided in the same way on a strike day as on a non-strike day. Patients in a life-threatening condition or requiring time-critical care and for whom there is no reasonable clinical alternative to the provision of patient transport services should continue to receive the service they require during a strike. We therefore will ensure through the MSL that all renal dialysis patients, all oncology and related cancer care patients, all palliative care patients, and any other high dependency patients continue to receive their NEPTS transport, and IFT Levels 1, 2 and 3 to be responded to in the same way on a strike day as on a non-strike day.

Territorial scope

With regard to the territorial extent of these regulations, we have not received views or input from key stakeholders through consultation and engagement with the devolved administrations in Scotland and Wales. The NHS organisations in Scotland and Wales we invited to participate either declined or did not respond. Representatives from the Scottish and Welsh governments acknowledged that employment law and industrial relations are reserved matters, but viewed steps to establishing MSLs in ambulance service as interfering with their devolved responsibility for health services.

Patient representative groups expressed concern that there should be consistency across Great Britain to ensure no disproportionate impact on patients across the territorial boundaries.

While the UK Government thinks that people across the UK should be able to be confident what types of situations the ambulance service will respond to on strike day, it recognises that responsibility for the operation of these services in Scotland and Wales lies with the devolved administrations.

For these reasons, we intend for the regulations to apply to England only at this time, rather than also including Scotland and Wales.

Wider options

In response to our consultation, some organisations put forward alternative suggestions for how to protect patients and services for those in most urgent need during strike action. In particular, there was support for improving and strengthening the voluntary derogations process. Currently there is no clear and consistent guidance on how to undertake these negotiations, and therefore the process is time-consuming and carried out in different ways across the country.

We will work closely with our partners to take forward this work, which alongside the implementation of the NHS Long Term Workforce Plan, will promote a simplified and smoother way of working between employers and trade unions during periods of industrial action, which puts particular pressure on relationships and resources.

Equalities and impacts

Some respondents to the consultation emphasised the importance of ensuring there is no disproportionate impact on patients who are more likely to need an ambulance, including those with protected characteristics - for example, the elderly, domestic abuse victims, pregnant women or people with disabilities or chronic illnesses. These conditions and situations would not necessarily point to a high ambulance response category, but they could mean people are particularly vulnerable if not responded to promptly. We expect the relatively high minimum service level as set out above will mitigate any issues associated with vulnerable patients, as they are more likely to receive an ambulance response with strong MSLs. Older people and people with disabilities in particular are more likely to use acute services and require help, even in Category 3 cases such as falls, which make up 10% of 999 ambulance calls. The government therefore believes that MSLs will have a positive equalities impact, particularly for those groups set out above. This is explored further in the impact assessment, which has been published alongside this consultation response.

It is expected that key organisations, such as the trade unions and ambulance trusts, would be required to familiarise themselves with the legislation and any relevant guidance produced to support the policy, and also incur ongoing administrative costs in complying with work notices for each strike. As previously mentioned, employers expressed concern around the financial cost to implement work notices due to the numbers of staff who would be required on a strike day. A full economic impact assessment has also been published, which provides further an analytical assessment of the estimated impacts of this policy.

Participants in the consultation also raised concern around the potential unintended consequences of implementing this legislation. Employers and trade unions noted the risk of employees engaging in action short of strike if they cannot go on strike, which they believe would be much more difficult for services to plan for and be more likely to impact on patients. As stated above, our intention is to also work with partners on strengthening the voluntary derogations process, to promote a better way of working together during periods of pressure, which would prevent the need for using work notices and therefore mitigate the risk of such action being taken.

Timing

Winter is the time of year where the health system is most consistently under pressure, due to the impact of flu and other cold weather related illness. We will seek to ensure the regulations come into force by the end of 2023 so that they can have the earliest impact.

Analysis

The following sections provide detailed analysis of how people responded to the questions in the consultation on MSLs in ambulance services.

The full data used in this section can be found in the accompanying data tables.

150 responses were received to the consultation. Members of the public made up the largest proportion of respondents (56%). Members of the ambulance service workforce were the second largest group responding (28%).

Other demographic breakdowns (age, ethnicity, sex, nation, region, distance from nearest hospital, disability) can be found in the accompanying data tables.

To preserve anonymity, low values (where frequency is lower than 5) have been suppressed throughout. These values are all noted in the tables below.

Proposed legislative change

To what extent do you agree or disagree with the proposed introduction of MSLs for ambulance services in the NHS?

There were 137 responses to this question, which are shown in the table below.

Responses	Total and percentage
Strongly agree	20 (15%)
Agree	6 (4%)
Neither agree nor disagree	7 (5%)
Disagree	20 (15%)
Strongly disagree	84 (61%)

Seventy-six per cent of respondents for this question in the consultation disagreed with the introduction of MSLs for ambulance services in the NHS, with 19% agreeing.

Opposition to the introduction of MSLs differed by type of respondent, but the majority of respondents in most groups disagreed. Seventy-nine per cent of the public opposed the introduction of MSLs, the second highest level of opposition after the ambulance workforce (80%). Opposition appeared slightly lower among non-ambulance health workforce (67%, 14 respondents) and organisations (50%, 10 respondents), although smaller respondent levels need caution.

Younger respondents were less likely to support MSLs (89% of 25 to 34 year olds and 90% of 35 to 44 year olds disagreed), as were males (83% disagreed).

There was a slight but statistically insignificant difference in opposition by distance from hospital (81% of those within 5 miles of a hospital compared to 72% who lived more than 5 miles). There was no clear difference in views by disability.

We received 71 responses to the open text portion of this question.

Among those who agreed with the introduction of MSLs in ambulance services, responses mainly reasoned that MSLs are needed to protect the public and maintain safety during strike action. A few respondents also expressed negative feelings towards trade unions, which they saw as endangering patients by organising strikes.

Among those who disagreed with the introduction of MSLs, comments mainly focused on the policy’s interaction with the ability to strike as a moral issue, and suggested that the government should instead address underlying issues in the ambulance sector (such as recruitment, retention and working conditions). Some also commented on the right to strike as a legal issue. Other themes included the view that current arrangements for strike mitigations already provide sufficient protection, concerns that MSLs would prevent the voices of ambulance staff from being heard (and therefore damage morale), and questioned the premise that ambulance services are not always safe on non-strike days.

In addition to the 150 on-platform responses to the consultation, we also received separate written responses from 11 stakeholder organisations. This analysis compiles these with organisational responses received through the online survey platform. We received responses from a range of stakeholder organisations, including trade unions, employer representatives, regulators, charities responding on behalf of particular patient groups and other interest groups.

Some organisations chose to take a neutral position on the question of whether MSLs should be introduced in the ambulance service. The majority of those that did take a position were opposed.

In response to this question, stakeholders agreed on the importance of maintaining patient safety in times of strike action. However, many raised concerns that the proposal fails to address underlying problems in the ambulance sector, including understaffing due to recruitment and retention issues. In this context, many were also uncomfortable with the possibility of staff being dismissed if they are named in a work notice but choose not to work.

Some took the view that MSLs could exacerbate these issues by damaging staff morale and worsening industrial relations. Those who thought the introduction of MSLs might damage industrial relations also highlighted several other potential unintended consequences. Firstly, some were concerned that MSLs might incentivise action short of strike (such as working to rule or overtime bans), which could be longer-lasting and more difficult for employers to manage. Secondly, some suggested that the proposal could create more uncertainty by incentivising unions to give only the minimum statutory notice of strike action. There were also concerns that tighter regulations and the threat of dismissal might encourage staff to communicate less with employers in the lead up to strike action, creating more uncertainty. Thirdly, stakeholders highlighted that MSLs would apply to local industrial disputes as well as national ones, with some suggesting that this had not been adequately considered in the impact assessment or consultation.

Trade unions expressed a preference for the current system of local, voluntary derogation agreements over MSLs. A few expressed the view that the act gives too much power to the Secretary of State to set MSLs irrespective of the views of relevant stakeholders and NHS employers themselves. Unions also disputed comparisons to other European countries made by the government and in the consultation and impact assessment, expressing their view that the UK already has more restrictive industrial relations laws than many European countries.

Several organisations raised concerns about the legal implications of MSLs. These included questions around the act’s interaction with Article 11 of the European Convention on Human Rights (the ‘right to strike’), and questions about how and against whom MSLs would be enforced. Many felt the proposal needed more clarity on the practicalities of implementing MSLs, for all parties involved. These included questions around the creation and implementation of work notices, the means and consequences of determining a reasonably necessary number or roster of staff, and if or how MSLs apply to specialist transfer and retrieval services (for example, air ambulances), which are managed by charities but supported by NHS staff.

To what extent do you agree or disagree that current arrangements are sufficient?

There were 148 responses to this question, which are shown in the table below.

Responses	Total and percentage
Strongly agree	77 (52%)
Agree	30 (20%)
Neither agree nor disagree	16 (11%)
Disagree	12 (8%)
Strongly disagree	13 (9%)

Seventy-one per cent of respondents for this question thought that current arrangements were sufficient on strike days. The public were most likely to see current arrangements as sufficient (77%), followed by members of the ambulance workforce (69%). A majority of non-ambulance health workforce (64%, 14 respondents) and organisations (60%, 10 respondents) also agreed that current arrangements were sufficient.

We received 49 responses to the open text portion of this question.

Those who disagreed that current arrangements are sufficient again emphasised the need to protect the public during ambulance strike action, particularly patients in life-threatening and emergency situations.

Among those who felt that current arrangements are sufficient, many responses referenced the ambulance strikes that took place between December 2022 and February 2023, arguing that, in their view, mitigations successfully balanced patient safety with the ability of workers to strike. Several of these responses emphasised that staff can and should be trusted to effectively protect patient safety during industrial action, as the people that know local services best. Conversely, some argued that it is not the government’s place to regulate industrial action in the ambulance service, and/or that it does not have the relevant expertise to set MSLs. Some respondents highlighted underlying issues and safety concerns in ambulance services on non-strike days, arguing that the government should instead focus on these problems.

Stakeholder organisations generally thought that current arrangements for mitigating strike action in the ambulance service are sufficient, and/or expressed a preference for improving these rather than introducing MSLs.

Many highlighted that it is already custom and practice for unions and employers to work together to provide ‘life and limb’ cover during ambulance strikes. Stakeholders generally felt that this had been sufficient to ensure patient safety during recent ambulance strikes between December 2022 and February 2023, though some described difficulties interpreting the scope of ‘life and limb’ as a principle. Some also pointed out that the Trade Union and Labour Relations (Consolidation) Act 1992 (TULRCA) already prohibits the endangerment of human life or serious bodily injury, although this is a higher threshold than the government is seeking to provide through MSLs.

Responses highlighted the significant work that had taken place during recent industrial action to plan and implement mitigations. A few responses also acknowledged that changes in patient behaviour had resulted in decreased demand on strike days. Trade unions particularly emphasised that they view industrial action as a last resort, and argued that they treat patient safety as their top priority when establishing voluntary derogations. Unions reported that on strike days, their representatives had frequently communicated with employers and clinicians in ambulance control rooms, to enable staff to return from the picket line and respond to calls as needed. Employers also highlighted that under current arrangements, derogation discussions typically begin as soon as employers are notified of strike action. They also questioned whether the proposed implementation of work notices would meaningfully change derogation timelines if employers and unions are still able to agree to changes within 4 days of strike action.

Some organisations highlighted that local expertise had been important in anticipating likely service demand on strike days and determining an effective response, while balancing the ability of staff to strike. Trade unions particularly felt that local relationships between employers, staff and union personnel had been vital in facilitating this cover, and that the prospect of MSL legislation had increased strain on these relationships. Given the reality of variation in local service needs (that is, differences in local population health and demography, and in workforce or management differences between ambulance trusts), several organisations suggested any national MSL would be a blunt tool, unable to provide an adequate balance of patient safety with the ability to strike.

While there was a consensus that current voluntary derogation agreements were preferable to MSLs, some stakeholders felt that the processes for establishing derogations could still be strengthened (and that this avenue should be pursued before new legislation). The most common suggestion was to provide more clarity around the definition of ‘life and limb’, to minimise the need for interpretation and improve consistency.

Territorial scope

To what extent do you agree or disagree that it is important to have consistent standards for minimum service levels in the event of strike action in the ambulance services across England, Wales and Scotland?

There were 148 responses to this question, which are shown in the table below.

Responses	Total and percentage
Strongly agree	27 (18%)
Agree	18 (12%)
Neither agree nor disagree	30 (20%)
Disagree	25 (17%)
Strongly disagree	48 (32%)

Around half (49%) of respondents disagreed that it was important to have consistent standards for MSLs in the event of strike action in the ambulance services across England, Wales and Scotland.

Responses by the public were split across agree (34%) and disagree (41%), with a relatively high proportion of ‘neither agree nor disagree’ (24%), which suggests some respondents may not have clearly understood the question or felt otherwise unable to comment.

Respondents from the ambulance workforce were most opposed to consistent standards for MSLs in ambulance services across England, Wales and Scotland (62%).

We received 50 responses to the open text portion of this question.

The consultation received very few responses from individuals or organisations based in Wales or Scotland, and we are therefore unable to comment on their particular views.

Not all the respondents who agreed it is important to have consistent standards for MSLs in ambulance services across England, Wales and Scotland were supportive of MSLs. Despite agreeing, some raised further objections to the policy (including arguments that the UK Government should instead address underlying issues), and some felt that current arrangements already provide enough consistency. Of those that were supportive, responses highlighted the importance of an equal, consistent experience for all ambulance staff and service users during industrial action.

Some respondents (including some who agreed that it is important to have consistent standards for MSLs across England, Wales and Scotland, and some who disagreed) felt that consistency would be best achieved by having minimum service or staffing levels year-round, regardless of industrial action.

Among those who disagreed that it is important to have consistent standards for MSLs in ambulance services across England, Wales and Scotland, many raised general objections to the policy (including arguments that the UK Government should instead address underlying issues and safety concerns). Some also highlighted the need to account for national, regional and local variation in service needs and operations across different parts of England, Wales and Scotland.

Many organisational responses referred only to the ambulance service in England, and therefore declined to comment on consistency across Wales and Scotland.

In response to this question, some organisations reiterated their overall objection to MSLs. A few highlighted the opposition of the Scottish and Welsh governments to the act, suggesting that the introduction of MSLs across England, Scotland and Wales would infringe on devolved matters.

More generally, some reiterated that local arrangements provide the most effective route to achieving safe cover, given that there are significant differences in how ambulances operate across regions.

A few organisations also expressed their view that it is important to have consistent standards for ambulances services regardless of whether strike action is taking place.

Inclusion of ambulance services

To what extent do you agree or disagree that the ambulance service should be specified as a relevant service where MSLs could be required on strike days?

There were 148 responses to this question, which are shown in the table below.

Responses	Total and percentage
Strongly agree	21 (14%)
Agree	13 (9%)
Neither agree nor disagree	14 (9%)
Disagree	24 (16%)
Strongly disagree	76 (51%)

Sixty-seven per cent of respondents disagreed that the ambulance service should be specified as a relevant service where MSLs should be required on strike days - slightly lower than 76% who disagreed with the introduction of MSLs in ambulance services (see the first question under ‘Proposed legislative change’ above).

Disagreement with ambulance service as a relevant service for MSLs was consistent across the public (67%), the ambulance workforce (71%), and the non-ambulance health workforce (71%, 14 respondents).

We received 44 responses to the open text portion of this question.

Among those who agreed that ambulance services should be specified as a relevant service where MSLs could be required, comments generally focused on patient safety, and the fact that ambulance services deal with immediate threat to life and limb.

Among those who disagreed, most comments raised general objections to MSLs in ambulance services. Some argued that working conditions in ambulance services needed to improve. Others drew comparisons with other emergency services, such as the army and police forces, where strike action is restricted but other compensatory measures are in place.

Some respondents highlighted the interdependency of ambulance services with other parts of the health system (such as A&E), arguing that this means isolating ambulance services as relevant for MSLs could be ineffective or counterproductive. Some of these respondents saw this as a reason to also introduce MSLs for other health services, but some saw it as a reason not to introduce MSLs anywhere in the system.

Organisational responses to this question were limited. Several stakeholders reiterated their opposition to ambulance MSLs, with some highlighting the importance of maintaining the right to strike and goodwill among staff.

A few stakeholders acknowledged the particular importance of effective mitigations during ambulance strikes (compared to other health and public services), to ensure safe cover for life-threatening and emergency incidents.

In this question and others, a few organisations suggested that further consideration should be given to the full range of staff groups theoretically included in ambulance service MSLs (such as nurses working in the ambulance sector).

Minimum level of service

Which of the following types of medical incidents should be responded to, even in times of strike action, if any?

There were 150 responses to this question, which are shown in the table below.

Response totals may sum to higher than the total base for questions where respondents could select multiple options. Percentages may also sum to more than 100 for these questions.

Responses	Total and percentage
Life-threatening cases or those needing immediate intervention and/or resuscitation (for example, major trauma and cardiac and respiratory arrest, among other incidents)	122 (81%)
Emergency cases including serious time-sensitive incidents (for example, strokes and heart attacks, among other incidents)	95 (63%)
Urgent issues that are not immediately life-threatening but need treatment to relieve suffering (for example, pain control) and transport or management at the scene such as falls, among other incidents	26 (17%)
Non-urgent cases that need assessment and possibly transport within a clinically appropriate timeframe	See note
None of the above	18 (12%)
Don’t know or prefer not to say	See note

Note: to preserve anonymity, low values (where frequency is lower than 5) have been suppressed.

A large majority of respondents (81%) said that life-threatening cases or those requiring immediate intervention and/or resuscitation should be responded to, even in times of strike action, with a smaller majority (63%) in favour of emergency cases including time-sensitive incidents. A low proportion of respondents (12%) said that none of the types of medical incidents should be responded to even in times of strike action.

While this question is not asking about agreement with MSLs, it does suggest widespread agreement with the need to respond to critical medical cases even in times of strike action.

We received 45 responses to the open text portion of this question (separate from the type-in ‘other’ option).

Many respondents reiterated objections to ambulance MSLs, and/or a belief that current arrangements provide sufficient cover for the necessary incidents. Some (particularly members of the workforce) referenced the December 2022 to February 2023 ambulance strikes as evidence that current arrangements have provided a sufficient level of cover.

Some respondents also argued that clinicians should have professional discretion about which incidents need a response on strike days, rather than setting this in legislation via MSLs. Several (particularly in the ambulance workforce) also raised concerns that too many ambulances are currently attending non-urgent incidents, regardless of whether industrial action is taking place. Some of these respondents therefore called for improvements to over-the-phone triage.

While some stakeholder organisations reiterated their objection to MSLs in this question by answering ‘none of the above’, there was some agreement in responses on the importance of ensuring cover for life-threatening cases during strike action. Several stakeholders were positive about the option of segmenting response to Category 2 calls, suggesting that this could support the clarification of ‘life and limb’ cover (as a preferred alternative to MSLs).

A few organisations, however, raised concerns about the use of call categories, pointing out that even calls in Category 3 can be extremely serious, with significant risks to patients if they receive no response or a delayed response during strike action. Similarly, some highlighted that the risk of harm to a patient can vary significantly depending on context, and can change over time. Stakeholders therefore suggested that any incident-based MSL should include provisions for reassessment, to allow a call to be ‘upgraded’ if a patient’s condition deteriorates.

Which of these ambulance services, if any, should be covered by MSLs in ambulance services?

There were 150 responses to this question, which are shown in the table below.

Response totals may sum to higher than the total base for questions where respondents could select multiple options. Percentages may also sum to more than 100 for these questions.

Responses	Total and percentage
999 emergency ambulance services	57 (38%)
Non-emergency patient transport services	9 (6%)
Inter-facility transfer services	18 (12%)
NHS 111	18 (12%)
Hazardous Area Response Teams	44 (29%)
Special Operations Response Teams	42 (28%)
Unexpected births in the community	36 (24%)
Healthcare practitioner call response	15 (10%)
None of the above	69 (46%)
Don’t know or prefer not to say	8 (5%)
Other	7 (5%)

Almost half (46%) of respondents said they did not want any of the referenced types of ambulance services to be covered by MSLs. The most commonly cited services to be covered by MSLs in ambulance services were 999 emergency ambulance services (38%), Hazardous Area Response Teams (29%) and Special Operations Response Teams (28%).

Legislative options

We have outlined some options below on how MSL regulations could operate. Which options, if any, do you agree with?

There were 150 responses to this question, which are shown in the table below.

Response totals may sum to higher than the total base for questions where respondents could select multiple options. Percentages may also sum to more than 100 for these questions.

Responses	Total and percentage
Requiring ambulance trusts to respond to all life-threatening and emergency incidents, provide NHS patient transport services, inter-facility patient transport services, including time-critical transfers for emergency treatment and essential critical infrastructure - for example, IT support	34 (23%)
Requiring ambulance trusts to respond to a specified list of medical issues, provide NHS patient transfer services, inter-facility patient transport services, including time-critical transfers for emergency treatment and essential critical infrastructure - for example, IT support	14 (9%)
Requiring ambulance trusts to respond to calls under the national ambulance response time categories (for example, in England all or a subset of Category 1, Category 2, Category 3 or Category 4 calls and equivalents in Scotland and Wales), provide NHS patient transfer services, inter-facility patient transport services, including time-critical transfers for emergency treatment and essential critical infrastructure - for example, IT support	11 (7%)
Requiring a percentage of service capacity to respond to 999 calls, provide NHS patient transfer services, inter-facility patient transport services, including time-critical transfers for emergency treatment and essential critical infrastructure - for example, IT support	6 (4%)
Requiring a percentage of staffing to respond to 999 calls, provide NHS patient transfer services, inter-facility patient transport services, including time-critical transfers for emergency treatment and essential critical infrastructure - for example, IT support	9 (6%)
None of the above	90 (60%)
Don’t know or prefer not to say	9 (6%)
Other	12 (8%)

A majority (60%) of respondents said they did not agree with any of the referenced options on how MSL regulations could operate, slightly lower than the proportion who disagreed with the introduction of MSLs (76%). The most supported of the options presented was “requiring ambulance trusts to respond to all life-threatening and emergency incidents, provide NHS patient transport services, inter-facility patient transport services, including time-critical transfers for emergency treatment and essential critical infrastructure - for example, IT support” (23%).

Policy scope

If MSL regulations are made, based on the requirement to name staff in work notices, which staff groups should be included within an MSL for the ambulance service?

There were 150 responses to this question, which are shown in the table below.

Response totals may sum to higher than the total base for questions where respondents could select multiple options. Percentages may also sum to more than 100 for these questions.

Responses	Total and percentage
Emergency operations centre staff including call handling, clinicians, supervisors, ambulance dispatch staff and navigators	32 (21%)
Paramedics (also including specialist paramedics, advanced paramedics, consultant paramedics)	36 (24%)
Ambulance crews	32 (21%)
Emergency care assistants	26 (17%)
Ambulance care assistants	21 (14%)
Emergency medical technicians	24 (16%)
Doctors, other clinicians, managers acting as commanders or in a leadership role and other support staff	24 (16%)
Hazardous Area Response Teams	28 (19%)
Special Operations Response Teams	24 (16%)
Don’t know or prefer not to say	See note
None of the above	92 (61%)
Other	See note

Note: to preserve anonymity, low values (where frequency is lower than 5) have been suppressed.

A majority (61%) of respondents said they did not want any of the referenced staff groups to be included within an MSL for the ambulance service if MSLs were based on the requirement to name staff in work notices. The most supported of the options presented were paramedics (24%), emergency operations centre staff (21%) and ambulance crews (21%).

Inclusion of wider health services

To what extent do you agree or disagree that other health services should be included in MSL regulations?

There were 148 responses to this question, which are shown in the table below.

Responses	Total and percentage
Strongly agree	18 (12%)
Agree	12 (8%)
Neither agree nor disagree	13 (9%)
Disagree	18 (12%)
Strongly disagree	87 (59%)

A majority (71%) of respondents disagreed that other health services should be included in MSL regulations, with 20% agreeing. Members of the public and the ambulance workforce were both mostly opposed to including other health services in MSL regulations (73%).

We received 30 responses to the open text portion of this question.

Some of those who agreed that other health services should be included in MSL regulations again highlighted the interdependency of healthcare services, and named specific services and staff groups including A&E, emergency departments, 111, GP services and midwives.

Many of those who disagreed reiterated objections to MSLs in healthcare or any other sector, as seen in previous questions.

As in the first question, some organisations declined to comment on whether or not they supported the introduction of MSLs for ambulance services or other health services. Those that did give a view were generally strongly opposed to expanding MSLs to include other health services, emphasising that if this were to be pursued, further consideration and sector-specific consultation would be needed. Concern was also noted that implementing MSLs in some health services but not others might establish an “uneven playing field” for industrial action in the sector, creating equality issues and potentially making strikes harder to manage across health systems.

Equalities and impacts

Are there particular groups of people, such as (but not limited to) those with protected characteristics, who would particularly benefit from the proposed minimum service levels for ambulance services?

There were 150 responses to this question, which are shown in the table below.

Responses	Total and percentage
Yes	20 (13%)
No	83 (55%)
Don’t know	47 (31%)

The majority (55%) of respondents said there were not any particular groups of people who would benefit from MSLs for ambulance services.

We received 14 responses to the open text portion of this question.

Respondents generally named groups of people they thought would be more likely to need an ambulance, including anyone who has a disability or long term health condition, is elderly, pregnant or is otherwise vulnerable.

Are there particular groups of people, such as (but not limited to) those with protected characteristics, who would be particularly negatively affected by the proposed minimum service levels for ambulance services?

There were 150 responses to this question, which are shown in the table below.

Responses	Total and percentage
Yes	28 (19%)
No	65 (43%)
Don’t know	57 (38%)

Almost half of respondents (43%) said there were not any particular groups of people who would be negatively affected from MSLs for ambulance services, with a minority (19%) saying there would be particular groups negatively affected by MSLs for ambulance services.

We received 19 responses to the open text portion of this question.

Some respondents thought that the ambulance workforce, and/or workers more generally, would be negatively affected by the introduction of ambulance MSLs (because the policy might infringe on their ability to strike and negotiate better working conditions). Some also thought there could be a second-order negative impact on service users (particularly those more likely to need an ambulance) and the general public, if MSLs were to exacerbate staffing and morale issues in the ambulance service or wider NHS.

Some stakeholders felt that people in ill-health and older people might benefit from the introduction of MSLs for ambulance services, because they are more likely to need to use them. Others, however, argued that these groups (and the general public) would be disadvantaged if MSLs were to have an overall negative effect on ambulance services by damaging morale and industrial relations and exacerbating recruitment and retention issues. It was also noted that people in more deprived areas have been found to be more severely impacted by ambulance delays outside of industrial action, so could also particularly benefit or be negatively impacted, depending on whether MSLs improve or worsen ambulance services.

Unions also expressed their view that women, workers from ethnic minority backgrounds and disabled workers are overrepresented in the public sector and healthcare workforces, so might be disproportionately negatively impacted by the introduction of MSLs in these wider sectors (particularly in relation to the right to strike and negotiating power). Recent NHS workforce statistics, however, show that none of these groups are significantly overrepresented in the ambulance service workforce (see Equality and diversity in NHS trusts and other core orgs December 2022 (xlsx, 7.1mb) on the NHS workforce statistics page).

1. Derogations are voluntary agreements to provide a certain level of cover, made between employers and trade unions in advance of strike action taking place. ↩

2. This relates to the ambulance response categories as set out by NHS England. See an overview of the sorts of cases in each response category. Wales and Scotland have different triage systems. ↩

3. See the Ambulance Collection - Web File Timeseries (xlsx, 550kb) on the NHS England Urgent and emergency care daily situation reports 2022 to 2023 page. ↩ ↩²